North Dakota Telepharmacy Project Hospital Telepharmacy Model

1
North Dakota Telepharmacy ProjectHospital
Telepharmacy Model

• Slide presentation by John S. Skwiera, R.Ph.,
  Heart of America Medical Center, Rugby

2
Hospital Demographics

• HAMC 25 Bed Acute Care
• TCMC 20 Bed Acute Care
• St. Aloisius Hospital 25 Bed Acute Care
• Carrington Health Center 25 Bed Acute
• Presentation Medical Center 25 bed Acute
• Mercy Hospital 50 Bed Acute Care
• Central Dakotas 41 Bed Specialty Acute
• Omnicell Med-Dispense JCAHO

3
Pharmacy Demographics

• 1 to 1.25 FTE pharmacists
• 0.5 to 2 FTE technicians
• Open 8AM to 5PM Monday through Friday
• Limited weekend hours (if any)
• Not open on Sunday (except SCCI)
• Only HAMC Presentation have the same pharmacy
  information management system (DHS). One has
  none.

4
Pharmacist Demographics

• Many have close ties to the area, i.e. family,
  farms, ranches, businesses
• Responsible for 24 hour call
• Limited additional resources
• Often live in the country (20-40mi)
• Long tenure at present positions
• Experienced pharmacists

5
The Dilemma

• Providing quality pharmacy services to patients
  in rural areas in a cost effective manner, and.
• Insuring that the pharmacist remains healthy and
  productive
• Insuring adequate coverage when the pharmacist is
  unable to be present on-site.

6
Some Cheese, Please

• Ill have a little bit of cheese with that whine
  now
• The simple fact recruitment is hard
• If relief help is found, the cost can be high,
  and the pharmacist possibly not well versed in
  hospital practice

7
A Question of Quality

• JCAHO standards i.e. proof of training?
• Knowledge of institutional policies and
  procedures?
• Credentials?
• IV admixture experience?
• Is a pharmacist with limited or no hospital
  pharmacy experience better than no pharmacist at
  all?

8
North Dakota Hospital Telepharmacys Goals

• To test the validity of the North Dakota model
• To provide consistent, quality patient care in a
  cost-effective manner
• To provide the pharmacist with a support
  structure that nurtures and sustains the
  pharmacists motivation to provide care in a
  rural setting
• To insure that the telepharmacy system promotes
  values of accuracy, dependability, integrity and
  accountability

9
SECONDARY GOALS

• Revenue generation by the hub site(s) by selling
  services to the remote site(s)
• Revenue generation has been a secondary
  consideration for now, as the concept was
  untested
• Expansion to accommodate 24/7 pharmacist
  availability

10
ND Hospital Telepharmacy Model

• Utilizes the unique skills and knowledge of
  technicians, nurses, pharmacists, physicians, and
  related health care professionals to optimize the
  care of the patient while overcoming current and
  future barriers to patient care

11
ND Hospital Telepharmacy Model

• Recognizes that technology can be limited in
  some rural hospitals
• Recognizes that the practice of pharmacy is still
  requires professional judgment
• Utilizes people and technology, each one
  complementing the other in the service of the
  patient
• Can combine the best of both to create a well
  rounded medication evaluation and delivery system

12
Focus on Quality

• The model uses the best personnel possible for
  medication order entry, evaluation, and
  dispensing of medications
• THE PHARMACY TECHNICIAN
• THE PHARMACIST
• Their unique skills and talents complement those
  of nursing and other health care professionals

13
Focus on Compliance

• CMS and JCAHO guidelines for pharmacist review of
  orders prior to the administration of
  medications
• Restriction of access to the pharmacy of
  non-pharmacy personnel
• State and federal regulations
• DUR

14
Focus on Cost Effectiveness

• Staffing the remote pharmacy with a technician is
  cost-effective
• Pharmacist coverage can cost less than an on-site
  pharmacist (in our current model it is less)
• Can be used by a hub site (provider of pharmacy
  services) as a revenue generator

15
Focus on Flexibility

• Can utilize the resources of seven pharmacists
  (depending on network configuration)
• Enables the pharmacist to work from home
  (infection control, inclement weather, family
  issues, ranching issues)

16
Telepharmacy Equipment Erik Christenson, PharmD
17
Telepharmacy Equipment
18
Telepharmacy Equipment
19
Telepharmacy Equipment
20
The Network

• A network of 7 hospital pharmacies
• Each pharmacy is connected to one another via
  Polycom and to Heart of America Medical Center
  telepharmacy PC
• Each hospitals pharmacy is also connected to the
  residence of the employee pharmacist via Polycom
  and PC (via DSL or satellite)
• Other connections may be made at the discretion
  of any partner

21
The Interactions

• Interaction between hospitals and/or homes via
  the Polycom unit (audiovisual)
• Access to the remote pharmacy information
  management system by the hub site (the site with
  the pharmacist present, either at home or another
  hospital)
• Such access is designed to insure that the
  proper information flow takes place to function
  effectively

22
Example

• Heart of America Medical Center can interact with
  Mercy Hospital via the Polycom (audiovisual
  interaction is mutual)
• HAMC (hub) pharmacist can access Mercys pharmacy
  computer system (remote) and can work with the
  pharmacy system only
• Currently Mercy cannot interact with HAMC.
• Therefore HAMC can provide pharmacist coverage
  to Mercy, but not vice-versa

23
The Procedure

• Order entry by the technician (remote)
• Evaluation verification of order entry by the
  supervising pharmacist -- this is accomplished by
  placing a hard copy of the physicians order
  under the document camera and comparing it to the
  technicians computer entry (hub)

24
The Procedure

• Identification of the drug and label by the
  supervising pharmacist -- this is done by placing
  the drug and label under the document camera
• Release of the drug
• Documentation of the transaction by the
  technician or pharmacist, either electronically
  or hard-copy
• So far no errors have occurred

25
Who Sees What?

• Each pharmacist can have access to another sites
  pharmacy information system, as allowed by the
  software -- ideally, it would be compatible
• Each pharmacist home site can view the
  pharmacists respective information management
  system\
• The pharmacist can view and approve a
  technicians work at the other sites, as allowed

26
Evaluate
27
Verify
28
Identify Release
29
Variations in Procedure

• CPOE
• Automated dispensing
• Nursing entry of orders
• After hours pharmacy coverage
• The current models procedures reflect an
  emphasis on technician order entry and dispensing
  with pharmacist verification during normal
  business hours.

30
Planning

• Decide what you want to accomplish
• Seek out partners
• Seek assistance from available resources
• Educate administrators, corporate executives, and
  staff

31
Gaining Approval
32
Development

• Apply for funding (if available)
• Determine components (both hospital and home
  units) and equipment needs
• Develop policies and procedures and business
  associate agreements/contracts
• Choose an ISP and equipment provider
• Obtain bids for equipment, installation, and
  servicing

33
Implementation

• Equipment installation and tests
• Business associate agreement (HIPPA)
• Contract include hold harmless clause
• Telepharmacy policies and procedures
• Dot the is, cross the ts

34
Followup

• Fine tune the system
• Evaluate for accuracy
• Implement CQI strategies if necessary to insure
  improvement
• Ongoing monitoring to insure that the system does
  not deteriorate

35
Pitfalls

• Institutional and corporate resistance
• Lack of ongoing financial commitment
• Challenges in terms systems compatibility and
  connectivity
• No common pharmacy information management system
• Security/HIPPA issues
• Demonic possession of equipment

36
Look Before You Leap

• Know what you are getting into
• Number of facilities
• Changes in workload
• Changes in scheduling
• Clear delineation of services
• Clear picture of reimbursement
• Insure adequate internet service
  

37
Personal Experience

• Our network pharmacists pay for telepharmacy
  services grudgingly and probably use it sparingly
• Until order review by a pharmacist is mandated
  this may not change
• If you build it, will they come?

38
Expenditures

• Polycom VSX, PCs, monitors, high resolution
  document camera(s), misc.
• DSL, T1
• Virtual Private Network (VPN)
• Equipment Installation
• Software as needed, i.e. Anzio, PC Anywhere
• Remodeling as needed
• Counter space ca. 5 linear feet
• Additional personal computers
• Optional cart (allows the telepharmacy equipment
  to be moved, i.e. to a nursing station)

39
Paperwork/Documentation

• Telepharmacy Policy/Procedure -- establishes
  standards of telepharmacy practice
• Business Associate Agreement -- establishes
  contractual agreements and outlines adherence to
  HIPAA regulations
• Contract reimbursement, services, hours.
• Grant requirements -- expense tracking and
  reimbursement
• Error/near-miss tracking

40
Telepharmacy Policy

• Must insure maintenance of quality care
• Must insure adequate evaluation and verification
  of medication orders, profiling and dispensing
• Must incorporate procedures for resolving any
  questions, discrepancies, or errors
• Must monitor errors and use CQI techniques to
  improve
• Must be in accordance with law to the
  satisfaction of the Board of Pharmacy or other
  regulatory agencies

41
Why It Works

• Excellent technicians
• Excellent pharmacist partners
• Support of CEOs Corporations (CHI)
• Support of NDSU, Custom Data, and the ND Board of
  Pharmacy
• Familiarity with five of the seven hospitals by
  doing locum work

42
Technicians

• ND technician training program w/certification is
  integral to telepharmacy
• NDSCS technician training program (on-site or by
  correspondence)
• Technician certification (PTCB)
• ND Board of pharmacy rules and regulations offer
  the technicians the opportunity to utilize their
  training
• Hire good technicians

43
Board of Pharmacy

• Provides guidance
• Insures that the publics health and wellbeing
  are not compromised
• Allows the pharmacist to practice pharmacy
• Is not overly restrictive as long as the
  pharmacists can show that telepharmacy operations
  are conducted in a prudent and safe manner

44
NDSU COLLEGE OF PHARMACY

• Dr. Charles D. Peterson
• Is a leader in the development and growth of
  telepharmacy
• Offers financial support (OAT grants) when
  available and warranted
• Offers a support structure for the development of
  the hospital model

45
Conclusion

• The North Dakota telepharmacy model is an
  alternative way to provide pharmacy services to
  rural ND hospitals
• The telepharmacy model is adaptable to a wide
  range of practice settings
• It works
• It is an evolving process

46
Dont wait until its too late, you may become
like me
47
Recommended Reading

• Rural Hospitals and Telepharmacy by Petra S.
  Berger (Risk Management and Patient Safety
  Institute)
• www.rmpsi.com

48
Contact Information

• John Skwiera, R.Ph.
• Heart of America Medical Center
• 800 South Main
• Rugby, ND 58368
• 701-776-5261, ext 2262
• pharmacy_at_hamc.com

49
Online Resources

• http//telepharmacy.ndsu.nodak.edu/
• A cornucopia of information
• Telepharmacy rules
• Hospital agreements
• Telepharmacy policy
• Business associate agreement
• Sample contract

50
NDSU

• NDSU Telepharmacy Coordinator
• Ann Rathke
• 701-231-5863
• Ann.Rathke_at_ndsu.nodak.edu

51
Board of Pharmacy

• ND STATE BOARD OF PHARMACY
• Howard Anderson, Jr. R.Ph.
• 701-328-9535
• ndpoph_at_btigate.com

52
Custom Data

• Ryan Jilek
• Custom Data, Inc.
• 701-483-3036
• www.telepharmacyconcepts.com
• www.customdata.com
• jilek_at_customdata.com

53
Special Thanks

• GPTRAC
• NDSU College of Pharmacy
• Jerry Jurena, CEO HAMC
• My wife, Ann